Skin, Hair, and Nails

Chapter 11

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 Health History:
General History
• Present health status: chronic illness,
medications, how keep it healthy, sun
exposure, changes in skin (look/feel/
sensation)
• Past medical/family history: past
problems, family member with problem;
skin cancer/autoimmune disorder?

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 Problem-Based History: Skin
• Pruritus—when started (suddenly/over time), where,
what makes worse/better, treatment, circumstances
when first noticed, dry/sensitive skin?
• Rash—when, where, initial appearance, itch/burn,
how long, what makes better/worse, treatment, other
symptoms, allergies, medications, irritants, exposure,
other family members have?
• Pain/discomfort—describe: started, location,
extend/spread, surface/deep, describe type, intensity,
constant/intermittent, what

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 Problem-Based History
• Lesions/changes in moles: describe,
location, first noticed, other symptoms,
appearance changed (describe)?
• Changes in skin color: generalized/
localized changes?
• Skin texture: how changed, excessively
dry/oily, when occurs, treatment?
• Wounds: location, how long, treatment,
wound healing problems?
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 Problem-Based History
• Hair: change experiencing, when, rate of
change, contributing factors, hair products,
diet change, distribution change?
• Nails: problems, when, chemical exposure,
brittle, pitting, chew, infection, keeping
clean, appear dirty?

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 Examination Techniques: Skin
• General survey (color, pigmentation, vascularity,
bruising, lesions, discolorations, odors)
– Systematic examination
• Head to toe exam: do with systematic examination
– Adequate lighting; may miss subtle changes
• Inspect for color: uniformity (consistent over
body surface) except vascular areas
– Whitish pink to olive tones to deep brown
– Sun exposed is darker

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 Examination Techniques: Skin

• Abnormal findings: evidence of

local/systemic disease
– Cyanosis
– Pallor
– Jaundice

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 Examination Techniques: Skin
• Inspect for localized color variation
– Intentional: tattoos, coining patterns
– Normal localized variations
• Moles, freckles, patches, striae

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 Examination Techniques: Skin
• Palpate for:
– Texture: smooth, soft, intact, even surface
(calluses)
– Temperature and moisture: warm/dry
– Mobility and turgor: move easily when lifted,
immediate return after released
– Thickness: varies with age/area (palms/soles
–thickest, eyelids thinnest)
• Callus: thick from friction/pressure

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 Examination Techniques: Skin
• Inspect/palpate for skin lesions: observable
change in structure
– Characteristics
• Light: color, elevation, borders
• Ruler: size (cm)
– Documentation: location, distribution, color,
pattern, edges, flat/raised, size
• )

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 Examination Procedures: Hair
• Inspect and palpate
– Scalp: surface characteristic; smooth without
flaking, scaling, redness, lesions;
• Hair: shiny, soft
– Quantity/distribution: balding patterns/hair loss
(male patterned)
– Texture: fine/coarse
– Color
• Inspect facial/body hair
– Distribution/quantity/texture: gender
differences
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 Examination Procedures: Nails
• Inspect:
– Shape: smooth/rounded; nail base angle =
160°
– Contour: flat/slightly rounded
– Consistency
– Color: pink, blanch (dark skinned,
yellow/brown with vertical lines)
– Thickness: smooth, uniform
– Cleanliness
• Palpate: nail base; firm/adheres to bed
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 Examination: Nails
• Abnormal nail findings
– Clubbing
– Thinning/brittleness
– Inflammation

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 Age-Related Variations:
Older Adults
• Anatomy and physiology: drier, decreased
perspiration decreased sebaceous/sweat
gland activity)
• Appearance (thin, parchment) decreased
dermal vascularity
– Folding/wrinkled appearance: loss of dermal
elasticity, collagen, mass
– Sharp/angular appearance over joints/bones,
deepening of hollows: decreased cutaneous
tissue

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 Age-Related Variations:
Older Adults
• Hair affected by hormonal changes
– Decreased melanin causes graying
– Thinning of scalp, axillary, pubic hair
– Follicles change size; terminal hair to vellus hair
(age-associated baldness)
– Transition of vellus to terminal hair in nares, on
tragus (men)
– Females develop facial hair (increased androgen,
increased estrogen)
– Loss of hair from trunk, extremities, axillary, pubic
area
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 Age-Related Changes:
Older Adults
• Hormonal changes (cont.)
– Decreased peripheral circulation: nail growth
slowed
– Nails get thicker, brittle, hard, yellow; ridges,
splitting
• Health history: same as for adults

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 Age-Related Changes:
Older Adults
• Examination: extra care; correlate history with
lesions (normal aging vs. cancer)
• Normal/abnormal findings
– ↑ pigmentation (sun exposure), hypopigmentation
– ↑ sun exposure causes ruddy, thickened skin
– Solar lentigo (liver spots): pigmented macules from
sun
– Seborrheic keratoses: warty lesions on face/ trunk,
(differentiate from actinic keratoses; premalignant)

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 Age-Related Variations:
Older Adults
• Normal/abnormal findings (cont.)
– Acrochordons (skin tags): tags of skin on
neck/chest
– Sebaceous hyperplasia: yellowish flat papules
with central depression
• Thin parchment skin over bony
prominences, dorsal surface: hands, feet,
forearms, lower leg
• Loose hanging skin on frame: loss of
adipose tissue/elasticity (tenting)
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 Age-Related Variations:
Older Adults
• Hair: gray, thin, coarse
– Symmetric balding in males
– Decreased amount of body hair (pubic,
axillary)
– Men: increase in amount/coarseness
nasal/eyebrow hair; women: increase in
coarse facial hair

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 Clients with Situational Variations

• Limited mobility: at risk for skin breakdown

– Secondary to pressure, body fluid pooling,
decreased ability to feel/change position
– Assess bony prominences
– Hands: calluses from operating wheelchair

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 Clients with Situational Variations
• Normal/abnormal findings
– Skin pressure points: initial pallor with pressure;
rapid return of color when removed
– If no blanching: stage I pressure ulcer
• Stages
– I: increased redness, unbroken skin
– II: partial-thickness skin loss (abrasion, blister)
– III: full-thickness skin loss; damage to
subcutaneous tissue
– IV: full thickness; invasion into deeper tissue/
bone
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 Health Promotion: Skin Cancer

• Most common of cancers (50% of all)

– Open sore more than 3 weeks, not healing,
bleeds, oozes, crusts
• Reddish patch may/not itch or hurt

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 Common Problems and
Conditions: Skin
• Hyperkeratosis (corn)
• Lesions (viral): warts, herpes simplex, H.
varicella, H. zoster, rubeola
• Lesions (fungal): tinea, candidiasis
• Lesions (bacterial): cellulitis, impetigo,
folliculitis, furuncle

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 Common Problems and
Conditions: Skin

• Lesions (arthropods): scabies, Lyme

disease, spider bites
• Lesions (abuse): bruise, bites, burns

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Common Problems and Conditions

• Hair
– Pediculosis, alopecia areata, hirsuitism
• Nails
– , ingrown toenail

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